You're constantly in pain; you have extreme fatigue and suffer from chronic headaches as well as irritable bowel syndrome. But is it really fibromyalgia?

Diagnostic Criteria
The difficulty with diagnosing fibromyalgia lies in the fact that, in most cases, laboratory testing appears normal and that many of the symptoms mimic those of other disorders. A definite diagnosis of fibromyalgia syndrome should only be made when no other medical disease can explain the symptoms. This is to say, fibromyalgia is a diagnosis of exclusion.

A proper history and physical exam coupled with blood work and/or x-rays may be done to rule out:

• Hormonal imbalance
• Anemia
• Infection
• Muscle disease
• Bone disease
• Nerve disease
• Joint disease
• Cancer
• Rheumatoid arthritis
• Hypothyroidism (including primary hypothyroidism, secondary hypothyroidism, Hashimoto’s thyroiditis, iodine deficiency goiter, and genetic thyroid enzyme defects). Thyroid-stimulating hormone levels should be checked routinely because this condition can mimic many of the symptoms of fibromyalgia
• Polymyalgia rheumatica

Electrical nerve and muscle testing, known as electromyography (EMG) or nerve conduction velocity (NCV), may also be done to check the muscles and nerves.

Fibromyalgia Tender Points
Upon physical examination, the fibromyalgia patient will be sensitive to pressure in certain areas of the body called tender points. To meet the diagnostic criteria, patients must have:

1. Widespread pain in all four quadrants of their body for a minimum of three months. Pain is considered widespread when all of the following are present:
   • Pain in the left side of the body
   • Pain in the right side of the body
   • Pain above the waist
   • Pain below the waist
   • Pain in the neck, front of your chest, mid-back, or low back

2. At least 11 of the 18 specified tender points of fibromyalgia (see diagram below). These are areas of pain on touch but without signs of redness, swelling or heat in the surrounding joints or muscles. For a tender point to be considered "positive" you must feel pain when someone pushes with their finger with an approximate force of 4kg (roughly the amount of pressure needed to change the colour of the skin). Some health care providers may use an instrument called an algometer during the examination of the patient to ensure that only a 4kg load is being placed. The location of the 18 tender points are:

   

   (1 & 2) Occiput: on both sides (bilateral), at the sub-occipital muscle insertions.
   (3 & 4) Low Cervical: bilateral, at the anterior aspects of the inter-transverse spaces.
   (5 & 6) Lateral Epicondyle: bilateral, 2 cm distal to the epicondyles
   (7 & 8) Knee: bilateral, at the medial fat pad proximal to the joint line.
   (9 & 10) Second Rib: bilateral, at the second costochondral junction, just lateral to the junctions on upper surfaces.
   (11 & 12) Trapezius: bilateral, at the midpoint of the upper border of the muscle.
   (13 & 14) Supraspinatus: bilateral, at origins, above the spine of the scapula (shoulder blade) near the medial border
   (15 & 16) Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
   (17 & 18) Greater Trochanter: bilateral, posterior to the trochanteric prominence.

Why Eleven Points?
Some experts believe that a person does not need to have the required 11 tender points to be diagnosed and treated for fibromyalgia. This criterion was originally intended for research purposes. A diagnosis of fibromyalgia may still be made if a person has less than the 11 of the required tender points so long as they have widespread pain and many of the common symptoms and associated syndromes connected to fibromyalgia, such as sleep disorders and irritable bowel syndrome.

If a patient has some symptoms but does not meet the tender point criterion, a diagnosis of "possible fibromyalgia syndrome" may be assigned. You should also remember that self-diagnosis is not advised and that you should consult a skilled medical professional to conduct a thorough examination.

What Goes with Fibromyalgia?
Commonly associated symptoms of fibromyalgia include:

• Fatigue
• Irritable bowel syndrome
• Sleep disorders
• Chronic headaches
• Jaw pain
• Cognitive or memory impairment
• Muscle pain or morning stiffness
• Painful menstruation
• Numbness and tingling in the extremities
• Dizziness or light headedness
• Skin and chemical sensitivities

Fibromyalgia Doctors
If your doctor is not familiar with fibromyalgia, the best thing to do is look for a local fibromyalgia support group meeting and ask for recommendations. This way, you’ll not only get a personal recommendation from someone who has a first-hand understanding of your issues, but it will enable you to meet others who share your concerns.

Limitations of the Diagnostic Criteria
Since fibromyalgia sufferers have typically normal laboratory or x-ray tests the above listed criteria are important for diagnosing and studying the syndrome. However, the criteria are not without their drawbacks.

First, the tender point paradigm assumes that fibromyalgia sufferers only experience pain in the 18 anatomical sites of the body. Recent research has made it evident that individuals with fibromyalgia are sensitive to painful stimuli throughout the body, not merely at the identified locations.

Second, many patients with fibromyalgia will often find that on a given day they will have less than the diagnostic 11 tender points in their body. Does this mean that some days you have fibromyalgia others you don’t? Obviously this is not the case.

Patient tenderness varies from day to day and, as a result, tender point counts on some days can be below the required 11 while on other days it may surpass it. Furthermore, some patients will not always have pain in all four quadrants of the body. Some experience pain only on one side or on the upper or lower half of the body. That being said, in the absence of a foolproof laboratory marker for fibromyalgia, the criteria explained above remains the best diagnostic tool for this condition.

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